LAPAROSCOPIC)CHOLECYSTECTOMY!
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1 Surgery>TechnicalScenario3 LAPAROSCOPIC)CHOLECYSTECTOMY MODULE:GENERALSURGERY TARGET:CT1 ST4GENERALSURGERY BACKGROUND: Laparoscopic cholecystectomy is one of the most commonly performed elective general surgical procedures in the UK. Laparoscopic surgery requires a slightly different skill set to that of open surgery and learning these skills handoeye cooordination and depth perception provides some challengesforthejuniorsurgeon. Laparoscopicsurgeryplacesagreaterdependenceuponvisualcuesashapticinputsaredampened throughthelonginstrumentsandtractionintheports.thissimulationallowsthetraineetopractice theirlaparoscopicskillsaswellasgainfamiliaritywiththestepsoflaparoscopiccholecystectomy,the instrumentsandequipmentthatareused.theuseofrealtissuesinthissimulationallowstraineesto developtheirtissueshandlingskills. RELEVANTAREASOFTHECURRICULUM Module3:Basicsurgicalskills Safeuseofsurgicaldiathermy Handletissuesgentlywithappropriateinstruments Basicsofsurgicalendoscopy INFORMATIONFORFACULTY Thisskillssimulationisusefulonanumberofdifferentlevelsandthereforemaybeusefulforlearners atdifferentlevelsofseniority. Forthemorejuniortrainee,theemphasisshouldbeuponlearningthestepsofthesurgical procedure,whichinstrumentsareinsertedintowhichportsandgainingdepthperception. ForthemoreseniortraineetheemphasisshouldbeuponcreatingappropriatecounterO tractionandidentifyingthecorrectplanefordissection neitherperforatingthegallbladder nordamagingtheliverbed. LEARNINGOBJECTIVES Inthisskillssimulationsessionlearnerswill: Revisethestepsoflaparoscopiccholecystectomy Gainfamiliaritywiththeinstrumentsandequipment Havetheopportunitytogaindepthperceptionbymanipulatingtissuesinalaparoscopicenvironment Learndifferentdiathermytechniques hookandheel HavetheopportunitytopracticeusingcounterOtractiontoidentifyanddeveloptheplaneusingreal tissues. Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
2 Surgery>TechnicalScenario3 SCENESETTING Location: Skillslab NB.NeedLOWtablesasboxtrainersincreasetheheightoftableworking.Placetheliverinthebox trainergallbladderfacingdownwards.stickthediathermyplateontotheundersideoftheliversothat atleastonequarteroftheliverisincontact.settingsshouldbeat25cutting25coagulation). Learnerswillworkinpairs oneascameraholdertheotherasprimarysurgeon.theywillthenswap over. Expecteddurationofscenario:45minsperlapchole OnOgoingfacultyfeedback EQUIPMENTANDCONSUMABLES Boxtrainereg.PharmabioticsBTS300Bodytorsosimulator 1,047eachPLUS Laparoscopicstacksystemeg.Storzgasinsufflationnotrequired)abilitytovideorecordfootageis desirable Alternatively+,+AnnexArtLaparoscopicsimulatorsystem includesboxtrainer,lightsource, camera willalsoneedvideomonitor+ Scopes either30degreeor0degree10mmscopesaresuitable Selectionoflaparoscopicports 2x12mmand2x5mm Selectionoflaparoscopicinstruments Endoclinch,Endograsp,EndodissectandEndoshears Hookdiathermy Endoclipper FingerOswitchdiathermyhandpiece ValleyLabdiathermymachine Force2secondhandauctionpricearound 750) ValleyLabdiathermyplatesE7506POLYHESIVENONREMRETEL 79.50for50 Incopads Porcinelivergallbladders availablefromfreshtissuesupplies 6.50each Burtbagforgallbladderretrieval NonOsterilegloves Clinicalwastebagsfordisposalatend PARTICIPANTBRIEFING Performalaparoscopiccholecystectomy duetodifferencesbetweentheporcinecalot striangle andhumanbiliaryanatomy,itmaynotbepossibletoseparatelydissectoutthecysticductandartery astheyareverysmall,thereforeitisacceptabletotakethesestructurestogether.aimtoplace3clips acrossthestructuresanddividethemleaving2clipsonthesidethatwillremaininthepatient,then proceedtodissectingthegallbladderofftheliverusingthehookdiathermy.attempttostayinthe correctplaneneithergoingintotheliverbednorperforatingthegallbladder. Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
3 Surgery>TechnicalScenario3 FACULTYBRIEFING Pleasewatchthelearnersduringthisskillssessionpayingparticularattentiontousageofthehook diathermy alwayskeepingthehookwithinview.alsopleasepayparticularattentiontothecountero tractionthatthelearnersapply. FREEZEOFRAMEOFTHESIMULATEDLAPAROSCOPICCHOLECYSTECTOMY Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
4 Surgery>TechnicalScenario3 SURGERY'>'TECHNICAL'SCENARIO'3'>'LAP'CHOLE' INFORMATIONFORPARTICIPANTS KEYPOINTS Insertionofgallbladderretractorthroughmostlateralofports. MaintainlateraltractiononHartmannpouchtoopenupCalotstrianglesufficientlyforsafedissection Keephookwithinviewatalltimes TractionandcounterTtractiontoassistwithidentifyingthecorrectplanefordissection Frequentadjustmentoflefthandgrasperasthedissectionprogressesinordertomaintainadequatetension. RELEVANCETOTHECURRICULUM Principlesofendoscopicsurgery Tissuehandling Safeuseofdiathermy WORKPLACETBASEDASSESSMENTS ThereisaPBAProcedureBasedAssessmentviaISCP. Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
5 Surgery>TechnicalScenario3 ADDITIONALINFORMATION Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
6 Surgery>TechnicalScenario3 ' Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
7 Surgery>TechnicalScenario3 DEBRIEFING POINTSFORFURTHERDISCUSSION ThissimulationhasestablishedconstructvalidityandskillsmaybeassessedbytrainedexpertratersusingeitherOSATStoolortheCATtool. Variable RespectforTissue TimeandMotion InstrumentHandling Knowledgeof Instruments UseofAssistants Flowofoperationand ForwardPlanning KnowledgeofSpecific Procedure Rating N/A Oftenusedunnecessaryforceontissueorcaused damagedbyinappropriateuseofinstruments Carefulhandlingoftissuebutoccasionallycaused inadvertentdamage Consistentlyhandledtissuesappropriately,with minimaldamage N/A Manyunnecessarymoves Efficienttimeandmotion,butsomeunnecessary moves Economyofmovementandmaximumefficiency N/A Repeatedlymakestentativeorawkwardmoveswith instruments Competentuseofinstruments,although occasionallyappearedstifforawkward Fluidmoveswithinstrumentsandno awkwardness N/A Frequentlyaskedforthewronginstrumentorused aninappropriateinstrument Knewthenamesofmostinstrumentsandusedthe appropriateinstrumentforthetask Obviouslyfamiliarwiththerequiredinstruments andknewtheirnames N/A Consistentlyplacedassistantspoorlyorfailedtouse assistants Gooduseofassistantsmostofthetime Strategicallyusedassistanttothebestadvantage atalltimes N/A Frequentlystoppedoperatingorneededtodiscuss nextmove Demonstratedabilityforforwardplanningwith steadyprogressionofoperativeprocedure Obviouslyplannedcourseofoperationwith effortlessflowfromonemovetothenext N/A Deficientknowledge.Neededspecificinstructionat mostoperativesteps Knewallimportantaspectsoftheoperation Demonstratedfamiliaritywithallaspectsofthe operation AcknowledgementstoLondonDeanerySkillsprogramZMiskovicD,MavroveliS,MaterN,HannaG Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
8 Surgery>TechnicalScenario3 Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
9 Surgery>TechnicalScenario3 Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope PARTICIPANT'REFLECTION' Whathaveyoulearnedfromthisexperience?Pleasetryandlist3things) Howwillyoubeabletoputintopracticewhatyouhavelearned? Whichskillswereyourparticularstrengths? Whichwereyourweakerskillswhereyouneedfurtherpractice?
10 Surgery>TechnicalScenario3 PARTICIPANT'FEEDBACK' Dateoftrainingsession:... LearnerGrade:... ' Strongly Agree Agree Neitheragree nordisagree Disagree Strongly Disagree Ifoundthissimulationuseful Iunderstandmoreaboutthe simulationsubject Ihavemoreconfidenceto dealwiththiscondition Thematerialcoveredwas relevanttome Pleasewritedownonethingyouhavelearnedtoday,andthatyouwilluseinyourclinicalpractice. Howcouldthisscenariobeimprovedforfutureparticipants?Thisisespeciallyimportantifyouhaveticked anythinginthedisagree/stronglydisagreebox. Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope
11 Surgery>TechnicalScenario3 Version9 May Editor:DrAndrewDarbySmith OriginalAuthor:MsACope FACULTY'DEBRIEF' 'TO'BE'COMPLETED'BY'FACULTY'TEAM' Whatwentparticularlywellduringthisskillssimulation? Whatdidnotgowell,oraswellasplanned? Whydidn titgowell? Howcouldtheskillssimulationbeimprovedforfutureparticipants?
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